CMM-609: Lumbar Fusion (Arthrodesis)

Lumbar fusion is covered only for clear, documented instability or specific surgical indications — e.g., degenerative or isthmic spondylolisthesis with dynamic instability or Meyerding ≥II, anticipated iatrogenic instability from required facet/pars resection, select recurrent or certain primary foraminal/extraforaminal herniations, discogenic single‑level DDD after ≥12 months of structured nonoperative care, and urgent/emergent fractures/infection/neoplasm with instability. Key requirements include recent (≤6 months) imaging showing the specified radiographic criteria, documented failure of prescribed nonoperative therapies for required durations, nicotine‑free status (blood cotinine ≤10 ng/mL or documented never‑smoker), documentation of symptom severity/functional impairment (often VAS/NRS ≥7), prior authorization when applicable, and fusion is considered not medically necessary for sole disc herniation (except listed exceptions), multi‑level DDD without instability, neurocompressive or facet‑only pathology, and many techniques/devices (e.g., AxiaLIF, interspinous devices, dynamic stabilization, endoscopic fusion) are considered investigational.